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White Rose Research Online URL for this paper: http://eprints.whiterose.ac.uk/138142/

Version: Accepted Version

Article:

Evans, CEL orcid.org/0000-0002-4065-4397, Christian, MS, Cleghorn, CL et al. (2 more authors) (2012) Systematic review and meta-analysis of school-based interventions to improve daily fruit and vegetable intake in children aged 5 to 12 y. The American Journal of Clinical Nutrition, 96 (4). pp. 889-901. ISSN 0002-9165

https://doi.org/10.3945/ajcn.111.030270

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Systematic review and meta-analysis of school-based

interventions to improve daily fruit and vegetable

intake in children aged 5 to 12 years

Keywords: fruit, vegetables, RCT, meta-analysis, schools, children

Word count: 4610

Running title: Review of school based interventions

No specific funding was obtained for this review

Charlotte E.L Evans, (Lecturer in nutritional epidemiology) Nutritional Epidemiology

Group, School of Food Science and Nutrition, University of Leeds, LS2 9LN

Corresponding address as above

Email address: c.e.l.evans@leeds.ac.uk

Telephone: 0113 343 35596 Fax: 0113 343 2982

Meaghan S. Christian, (PhD student) Nutritional Epidemiology Group, School of Food

Science and Nutrition, University of Leeds, LS2 9LN

Christine L. Cleghorn, (Research Fellow) Nutritional Epidemiology Group, School of

Food Science and Nutrition, University of Leeds, LS2 9LN

Darren C. Greenwood, (Senior Lecturer) Biostatistics Unit, Centre for Epidemiology

and Biostatistics, University of Leeds, LS2 9LN

Janet E. Cade (Head of Group) Nutritional Epidemiology Group, School of Food

(3)

List of authors last names for the purpose of PubMed indexing (in alphabetical order)

Cade Christian Cleghorn Evans Greenwood

Abbreviations

(4)

Abstract

1

Background: No reviews to date have assessed the impact of a range of multi- and single-

2

component school based programs on daily fruit and vegetable intake using meta-analysis. 3

Objectives: The aim was to quantify the impact of school-based interventions on fruit and

4

vegetable intake in children aged 5 to 12 years. 5

Design: A systematic literature review was carried out to identify randomized and

non-6

randomized controlled trials based in primary schools and designed to increase portions of 7

daily fruit and/or vegetable intake. Medline, Cochrane libraries, Embase, PsychInfo and 8

Educational Information Centre were searched from 1985 to 2009. Data was extracted and 9

mean effect sizes were calculated using random effects models. 10

Results: A total of 27 school-based programs involving 26,361 children were identified that

11

met the inclusion criteria and assessed daily weight of fruit and vegetable intake combined, 12

fruit intake only or vegetable intake only; and 21 were used in meta-analyses. The results of 13

the meta-analyses indicated an improvement of 0.25 (95% CI 0.06, 0.43) portions of fruit and 14

vegetable daily intake if fruit juice was excluded and an improvement of 0.32 (95% CI 0.14, 15

0.50) portions if fruit juice was included. Improvement was mainly due to increases in fruit 16

consumption, not vegetables. The results of the meta-analyses for fruit (excluding juice) and 17

vegetables separately indicated an improvement of 0.24 (95% CI 0.05, 0.43) portions and 18

0.07 (95% CI -0.03, 0.16) portions respectively. 19

Conclusions: School-based interventions moderately improve fruit intake, but have minimal

20

impact on vegetable intake. Further studies are needed to address the barriers for success in 21

changing dietary behaviour, particularly in relation to vegetables. 22

(5)

Introduction

24

The long-term health benefits of a diet high in fruit and vegetables in adulthood are well 25

documented. High intakes of fruit and vegetables are associated with a reduced risk of all 26

cause mortality (1) many cancers, (2-4) CVD (5-6) and determinants of CVD (7-11) major 27

causes of death in developed countries. (12) High fruit and vegetable intakes may also be a 28

risk factor for obesity (13) although this is disputed. (14-15) High fruit and vegetable intake 29

is associated with a better quality diet lower in energy dense foods and higher in fibre. (16-30

18) and findings from the global Burden of Disease 2000 study suggest that 4.4% of the 31

overall burden of disease in Europe is attributable to low intakes of fruit and vegetables. (19) 32

Childhood levels of fruit and vegetables may be related to intakes in later life (20) resulting in 33

close links between poor intakes in childhood and adulthood. Surveys of children’s fruit and 34

vegetable intake have reported low intakes of fruit and vegetables in most American, 35

European and Australian children of between 2 to 3 portions per day, (16, 21-28) well below 36

the 5 portions (400g) recommended by many government departments of health. (29-30) 37

A range of potentially modifiable characteristics are reported to be associated with higher 38

intakes of fruit and vegetables in children. These include good availability and accessibility, 39

(31-38) taste preference and lack of neophobia, (34, 37, 39) better home support (40) 40

knowledge of the national recommendations, (31, 41-42) interested in a healthy diet, (42-44) 41

and verbal praise. (38, 45) These factors provide a wealth of information to shape the design 42

of school and community based interventions to increase fruit and vegetable intake in 43

children and have been incorporated into intervention programs. (46) Single component 44

programs provide free or subsidized fruit to children to increase availability while multi-45

component programs provide a range of components such as nutrition education in the 46

curriculum, improvement of the school environment to enable healthy choices, and 47

communication with parents to increase family support. 48

A number of reviews of school programs to improve fruit and vegetable consumption have 49

been conducted, (47-51) two of which have included a meta-analysis enabling the impact of 50

programs to be quantified. Of the two reviews which included meta-analysis, one included a 51

small number of studies (51) and one pooled studies where fruit and vegetable intake was 52

assessed either over the school day or over the whole day, resulting in a high level of 53

(6)

programs as it did not take into account the fact that children may potentially increase their 55

consumption of fruit and vegetables while at school and compensate with reductions in home 56

consumption. (52) This high quality review is the first to provide a meta-analysis of a wide 57

range of multi-component and single component studies which measured the impact of 58

school based programs on daily fruit and vegetable consumption. Advanced analysis 59

techniques were used and the impact of programs was reported in terms of numbers of 60

portions of fruit and vegetables. Important sources of heterogeneity were taken into account 61

for the first time by presenting the results from studies which measured fruit and vegetables 62

but not fruit juice. This is important as reviews of the health benefits of fruit and vegetables 63

generally exclude juice which may have different associations with health outcomes. Results 64

of the impact on fruit and vegetables separately are reported for the first time in meta-65

analyses. 66

Improvements in daily fruit and vegetable consumption have the potential to achieve 67

significant public health benefits and this review identifies school-based trials targeting fruit 68

and vegetable intake in children aged 5 to 12 years to assess the impact of these programs. 69

Methods

70

Search strategy

71

An unpublished protocol was designed and agreed by all authors at the start of the review. 72

The following bibliographic databases were searched: the Cochrane Central Register of 73

Controlled Trials, OVID MEDLINE (1986 to 2009), Global Health (1973 to 2009), 74

PsychInfo (1987 to 2009), Educational Resources Information Centre (1985 to 2009), 75

EMBASE and CINAHL. The search strategy method for MEDLINE included research terms 76

in the following areas: child, fruit, vegetable, specific fruits and vegetables, public health, 77

health behavior, health promotion, health education, intervention studies and diet. This was 78

adapted so it could be used for the other databases, using keywords when MeSH terms were 79

not available. Reference lists were searched for additional citations. 80

Inclusion and exclusion criteria

81

Dietary intervention studies in a school setting involving children aged between 5 and 12 82

years (at the start of the intervention) were included. Trials (with or without randomization) 83

(7)

standard assessment measures such as food diaries using weighed/non-weighed methods, 24 85

hour diet recall, or food frequency questionnaires. 86

Studies were excluded if the intervention focused on eating disorders, such as anorexia 87

nervosa or bulimia, or if data on children of this age group could not be extracted separately 88

from other age groups. Trials involving fewer than ten participants were also excluded as 89

were those that included only obese children. 90

Trials were excluded if fruit and vegetable intake was measured solely on daily frequency of 91

consumption of fruit and vegetables rather than amount or portions consumed using a 92

standard portion size, as the weight of a piece of fruit or vegetable can vary. Studies were 93

excluded if they did not include a measure of variation such as standard deviation or standard 94

error. Studies were excluded if they did not report total daily fruit and vegetable 95

consumption, for example if they reported consumption at school only. Studies that only had 96

more than 2 years follow up were excluded as bias was likely to be considerable with loss to 97

follow up. 98

Definitions of exposure and outcome

99

The main outcome was the difference in portions (total weight in grams/80g) of fruit and 100

vegetables, separately and combined, consumed daily, excluding potatoes between the 101

intervention and control group. This is the agreed portion size for fruit and vegetables and no 102

government has set a smaller standard portion size for children. 103

The benefits of fruit juice consumption are not as clear as the benefits of fruit and vegetable 104

intake. Therefore, trials that included fruit juice together with fruit and vegetables were 105

analysed separately. Alternative wording from portion such as serving or serve were checked 106

to ensure that this was equal to 80g. If the portion or serving was different from 80g this was 107

recalculated. The US serving of half a cup of vegetables or medium size piece of fruit were 108

taken to be equal to a portion of 80g. 109

Selection of the studies

110

Two independent reviewers were involved in the study identification and data extraction. In 111

the first round of initial screening, the title and abstract of each article was checked for 112

eligibility by one of the two reviewers. Articles were excluded from the title and abstract if 113

they clearly did not meet inclusion and exclusion criteria as judged by the reviewer. In the 114

(8)

article was assessed for eligibility by both reviewers. Any disagreement between the two 116

reviewers on whether the article was eligible was resolved by discussion between the 117

reviewers, where necessary in consultation with a third reviewer. 118

Data extraction

119

Data was extracted by two independent members of the team (but not in duplicate). All the 120

data extracted was checked by a third member of the team trained and experienced in data 121

extraction. Data was extracted on data collection methods, length of program, drop-outs and 122

analysis methods. All studies were summarized according to the following aspects: type of 123

intervention, selection of population, outcomes, baseline and follow-up measures and 124

statistical analysis. Data on sample size, sample age, date and location of the study, type of 125

control group and unit of randomization were also extracted. 126

Wherever results for more than one follow-up period were reported, the longest follow up 127

period was used in the meta-analysis. The different types of activities included in the 128

intervention program were identified for each study. These included the following pre-129

specified elements: school lessons as part of the school curriculum; communications (either 130

with parents through newsletters or with students and teachers at school); food provision such 131

as availability of fruit and vegetables at lunchtime or in tuck-shops; free fruit and/or 132

vegetable distribution, food marketing such as incentives to buy more fruit and vegetables at 133

lunchtime including point of purchase incentives; food preparation and/or tasting during 134

school; home based projects including home-work carried out with the help of parents; 135

general improvements in the school environment (used if specific school based elements were 136

not described); community and industry involvement such as supermarkets or industry 137

partners. The final element reported by mainly US studies was goal setting and problem 138

solving, which indicated an over-arching theory based study of planned behavior was used. 139

Quality assessment of studies

140

Assessment of the quality of the trials was based on three criteria; reporting of sequence 141

generation criteria, allocation concealment and blinding of participants, personnel or outcome 142

assessors. Trials were considered to be at high risk of bias if none of the criteria were met, at 143

medium risk of bias if 1 or 2 of the criteria were met or at low risk of bias if all three of the 144

(9)

Statistical analysis

146

Statistical analysis was carried out in Stata version 10. Random effects models were used for 147

all meta-analyses to determine pooled estimates of differences in portions of fruit and 148

vegetables consumed in the intervention groups compared to control groups. If results were 149

reported as change from baseline to follow up in each group difference between groups was 150

calculated using the t-test. Heterogeneity was assessed using the I2 statistic, which describes 151

the proportion of total variation attributable to between-study heterogeneity. (53) I2 values of 152

less than 30% were considered to be low, values between 30-50% low to moderate, values 153

between 50-75% moderate to high and values above 75% high. I2 values of more than 50% 154

indicate that caution should be used when drawing conclusions from the data.(54) Forest 155

plots were examined to review heterogeneity between studies. Possible sources of 156

heterogeneity were explored, and included: trial design (randomized or not randomized), 157

geographical location, intervention type, diet assessment methodology, children’s age and 158

length of follow-up. Funnel plots were used to visually check for asymmetry and to 159

determine the possibility of publication bias. (53) 160

Results

161

Literature search

162

The literature search outlined in the methods identified 2722 potential papers, including 316 163

duplicates (312 identified at the first stage and 4 identified at the screening stage): 592 papers 164

from Embase, 100 from Psychinfo and the remainder from Medline. A total of 67 papers 165

potentially meeting all the criteria as a result of screening titles and abstracts were identified. 166

2,656 papers were excluded (before de-duplication) based on the predetermined exclusion 167

factors. Many papers were excluded on medical grounds such as eating disorders (12 168

studies), nut allergy (396 studies) or other medical conditions that concerned negative aspects 169

of plants on health (711 studies). A number of papers were excluded where the outcome was 170

not daily weight of fruit and vegetables (439 studies) or were not controlled trials (1072 171

studies). Some studies were excluded due to the age of the children (25 studies). Scrutiny of 172

the remaining 67 papers identified 40 further papers for exclusion resulting in 27 studies 173

remaining. Reasons for exclusion at this second stage are provided in figure 1 with ‘wrong 174

age group and outcome other than daily weight of fruit and vegetables as the primary reasons 175

(10)

A summary of the studies included in the qualitative review on daily intake are displayed in 177

table 1. The sample size of each study represents the number of children included in the

178

analysis with baseline and follow up data available. The total number of participants 179

included in all studies was 26,361 with a mean of 909 children per study (median of 486). 180

Programs delivered a variety of interventions delivered over a range of 3 months for mainly 181

curriculum based programs to two academic years for many of the more complex programs. 182

The majority of the interventions consisted of more than one component and therefore were 183

categorized as multi-component programs. These interventions often comprised a home and 184

school element and tended to have a longer follow up time period than single component 185

programs. The single component programs were mainly free or subsidized fruit distribution 186

schemes. In most cases, control groups were either reported to receive an intervention at a 187

later date or usual care. Some studies did not report information on the control group and two 188

studies by Bere reported that the control group received a paid subscription for fruit 189

compared to the intervention group which received free fruit.(55-56) The unit of 190

randomization was normally the school but in two trials the unit of randomization was the 191

class(57-58) and in one study was the region.(59) The median difference in daily fruit and 192

vegetable intake between the control and intervention group for all studies included in the 193

qualitative review was 0.6 portions based on 27 studies with intervention groups having 194

higher intakes on average. 195

Six studies were excluded at the meta-analysis stage due to lack of measures of variation 196

(standard deviation, standard error or confidence interval) (57, 60-64) One study reported 197

total sample size but not sample size for each group. In this case the sample size was 198

estimated by assuming equal numbers of children in each group and the study included. (65) 199

One author replied to the request for further information on sample size for the control and 200

intervention group and was also included. (66) 201

All papers included reported fruit and vegetable intake over the whole day but some also 202

included fruit juice in the reported difference between groups.(65-68) Inclusion of fruit juice 203

was a strong determinant of heterogeneity and therefore the primary analysis (see figure 2) 204

included studies where only fruit and vegetables and not fruit juice were measured. Due to 205

the fact that this was not decided a priori a sensitivity analysis including all studies was 206

carried out in addition to the primary analysis (see figure 3). Three studies in the meta-207

analysis reported total consumption of fruit and vegetables and also fruit juice (65-66, 68) 208

(11)

meta-analyses are presented with differences in daily fruit only (figure 4) and vegetable 210

intake only (figure 5). 211

In the primary meta-analysis to determine differences in fruit and vegetable consumption 212

excluding fruit juice, the pooled estimate for interventions reported a daily difference of 0.25 213

portions (95% CI 0.06, 0.43 portions) with higher levels of fruit and vegetables in the 214

intervention group (figure 2). The difference between groups was significantly different from 215

zero (p<0.01). The I2 value was 49% (95% CI 0, 74%, p=0.04) indicating moderate levels of 216

heterogeneity. A funnel plot indicated that there was some suggestion of slight asymmetry 217

(plot supplied as supplementary data), but the Egger's test for asymmetry was not statistically 218

significant (p=0.58). In the sensitivity analysis to determine differences in fruit and vegetable 219

consumption including fruit juice, the pooled estimate for interventions reported a daily 220

difference of 0.32 portions (95% CI 0.14, 0.50 portions) with levels of fruit and vegetables 221

higher in the intervention group (figure 3). This difference was significantly different from 222

zero (p<0.01). Heterogeneity measured using I2 was moderate to high at 62% (95% CI 31, 223

79%, p<0.01). A funnel plot indicated that there was some suggestion of slight asymmetry 224

(plot supplied as supplementary data), but the Egger's test for asymmetry was not statistically 225

significant (p=0.21). 226

The meta-analysis of difference in fruit only, excluding fruit juice (figure 4) reported that 227

fruit was 0.24 (0.05, 0.43) portions higher in the intervention group. This difference was 228

significantly different from zero (p=0.01). However, heterogeneity was high with an I2 value

229

of 78% (95% CI 60, 87%, p<0.01). A funnel plot indicated that there was asymmetry (plot 230

supplied as supplementary data), and the Egger's test for asymmetry was statistically 231

significant (p=0.02). An analysis on all studies including those with fruit juice produced 232

similar results. The difference between groups was 0.28 (95% CI 0.12, 0.44) portions for all 233

studies which was significantly different from zero (p<0.01). Heterogeneity as denoted by I2 234

was high at 78% (95% CI 63, 86%, p<0.01) (forest plot not shown). Differences in vegetable 235

intake between control and intervention groups were much smaller (figure 5). A meta-236

analysis of vegetables only which included studies with fruit juice indicated an effect size of 237

0.07 (95% CI -0.03, 0.16) portions which was not significantly different from zero (p=0.16). 238

Heterogeneity was moderate to high with an I2 value of 72% (95% CI 54, 83%, p<0.01). A 239

funnel plot indicated that there was some suggestion of slight asymmetry (plot supplied as 240

supplementary data), but the Egger's test for asymmetry was not statistically significant 241

(12)

An investigation into potential sources of heterogeneity using meta-regression analysis found 243

no statistically significant associations between the estimates and whether schools were 244

randomized, not randomized or not made clear, trial design (multi-component or single-245

component), age of the children, type of dietary assessment or length of follow up (see Table 246

2). However there were non-statistically significant trends in the pooled estimates for trial 247

design. The pooled estimate for single-component studies was smaller, although 248

heterogeneity was higher than for all studies combined. Five studies reported results for two 249

follow-up periods. In three studies, Ransley,(52) Baranowski(66) and Reynolds,(65) the 250

interventions continued beyond the first follow-up data collection point. In two studies (56, 251

69) the final follow-up collection period was more than three months after the completion of 252

the intervention. Data reported at the latest follow up period was used for each study. 253

Quality of studies included in the meta-analyses

254

The quality of the 22 trials included in the meta-analyses was generally poor with evidence of 255

high risk of bias. One study reported on all three criteria and was therefore judged to be at 256

low risk of bias. (70) Ten studies reported on one or two criteria and were therefore judged 257

to be at medium risk of bias. (52, 58, 63, 66-67, 71-75) The remaining 11 trials were judged 258

to be at high risk of bias and did not clearly report sequence generation criteria, allocation 259

concealment or blinding of participants, personnel or outcome assessors. 260

Discussion

261

Main findings

262

This review provides the first meta-analysis to quantify the impact of a range of school-based 263

interventions on daily consumption of fruit and vegetable intake in children aged 5 to 12 264

years. It is also the first review to quantify the differences in impact on vegetable compared 265

with fruit intake. School-based interventions of all types were estimated to improve daily 266

fruit and vegetable consumption by an average of a quarter to a third of a portion; equivalent 267

to 20-30g daily increase. Although most schemes aim to improve intake of both fruit and 268

vegetables most fail to increase vegetable intake by a useful amount with most of the 269

improvement in fruit intake. Studies that included fruit juice when assessing consumption of 270

fruit and vegetables tended to have higher intakes of fruit, juice and vegetables at baseline 271

(13)

strongly associated with health outcomes attenuated the impact of programs on daily fruit and 273

vegetable intake. 274

Comparison of different types of programs

275

School based interventions generally fall into two main categories, multi-component 276

programs that motivate and engage children and families to change their eating behavior and 277

single component programs that provide and distribute free or subsidized fruit and/or 278

vegetables. In this review, the multi-component programs tended to result in larger 279

improvements in fruit and vegetable intake but are diverse and can potentially be difficult to 280

replicate without considerable time, man-power and funds.(48) How well interventions are 281

implemented are reported to determine the impact of a program.(76-77) The single 282

component studies including free and subsidized fruit and vegetable distribution schemes 283

tended to be less effective although there were too few studies included to enable firm 284

conclusions to be made. Distribution schemes have recently been introduced in some schools 285

as part of national policies to increase children’s fruit and vegetable intake. These schemes 286

may offer little in terms of learned permanent improvement on children’s eating habits; 287

however fruit and vegetable intake may be moderately improved while receiving the fruit. 288

Teachers rating programs for ease of use, rate distribution programs easier to implement than 289

multi-component programs, (78) therefore long-term distribution programs may be a useful 290

option for governments. 291

Comparisons with previous reviews

292

Previous reviews based on qualitative analysis without meta-analysis report increases of 0 to 293

1 servings of fruit and vegetables per day. (49) (50) The results obtained here are similar to 294

those of a previous meta-analysis of seven studies, which reported an increase of 0.4 portions 295

of fruit and vegetables. This previous review included mainly multi-component studies and 296

did not exclude studies on the basis of including fruit juice which may explain the slightly 297

higher effect. (51) A recent review of programs to improve fruit and vegetable intake 298

stratified by type of intervention concluded that computer based interventions were the most 299

successful type of program and multi-component programs had no impact. This conclusion 300

was based on two analyses. Firstly a meta-analysis of only two programs using computer 301

games, one of which did not include fruit and vegetable intake over the whole day (only the 302

school day) and one of which included fruit juice. Secondly, the conclusions were based on 303

(14)

but due to high levels of heterogeneity as a result of including programs measuring only fruit 305

or vegetable intake and programs assessing fruit and vegetable intake over part of the day, it 306

was not possible to make firm conclusions.(47) In this review it was established that there 307

are currently not enough studies assessing daily intake of fruit and vegetables to determine 308

the impact of different types of studies although we identified a trend that multi-component 309

studies are more effective than single component-studies. 310

Strengths of this review

311

This review had a number of strengths. A range of single and multi-component programs 312

were included from different countries. Robust review methods were employed including the 313

use of a range of databases to find papers from a variety of sources and the use of two 314

reviewers to determine inclusions and exclusions. Furthermore, formal quantification of the 315

pooled estimates was carried out using meta-analysis. Studies were included that reported 316

frequency of consumption of fruit and vegetables as well as standard portion sizes or weight 317

in grams. 318

Measures were taken to reduce heterogeneity by restricting age group and only including 319

studies where standard methods of assessment were used. Fruit and vegetable intakes have 320

been shown to be underestimated by some methods (79) but no substantial differences by 321

assessment method were identified in this review. Studies that focused on obese children 322

were excluded as they may be expected to be more prepared to change their diet than children 323

in general. 324

Limitations of this review

325

The protocol was designed in 2008 using a Cochrane review protocol as a template and all 326

authors were involved in the design and agreement of the protocol. However, the protocol is 327

unpublished which is sub-optimal in meta-analysis. 328

Many studies published in this area are of poor quality design without a control group or with 329

poor randomization methods leading to biased reporting. Reporting of results was not 330

consistent and a number of studies did not report both fruit and vegetable consumption 331

combined. Successful programs may not have been included in the analysis due to a lack of 332

(15)

Future strategies

334

Some components from earlier multi-component programs have been incorporated into 335

national policy in some countries. For example, the curriculum in many countries includes 336

specific lessons on healthy eating.(80) In the UK children aged 4 to 7 years receive free fruit 337

and vegetables and receive a school meal meeting food based standards which include daily 338

fruit and vegetable provision, both of which are elements of recent multi-component 339

programs. However, there are some areas where very few, or no, trials have been reported in 340

this age group, such as studies where cooking or school gardening is the main component. 341

(81) Some types of studies such as tasting of fruit and vegetables were not included in the 342

review because of a lack of assessment of daily fruit and vegetable intake in these mainly 343

laboratory based studies; (82) however, exposing children who disliked vegetables for 14 344

days has been reported to increase liking and consumption of vegetables. (83) There is also 345

evidence that schools participating in gardening programs increase fruit and vegetable, 346

vitamin A, vitamin C and fibre intake. (84) Future RCTs in these areas may be expected to 347

further contribute to an increase in the intake of vegetables in particular which is badly 348

needed. There should also be a focus on families and home consumption of fruit and 349

vegetables. 350

Very few studies collected follow-up data a full year after the intervention, particularly if the 351

intervention was less than 6 months in duration. Those that did collect this type of data saw 352

moderate long-term impact on fruit and vegetable intake, (56) indicating that if intervention 353

programs are to have an impact on children’s health they must run continuously over long 354

periods of time and should not be considered as one-off solutions. Based on these results, 355

school based programs could be expected to increase fruit and vegetable intake by a quarter 356

to a third of a portion, but there is limited evidence of the impact on future health outcomes 357

from a daily increase of a third of a portion of fruit and vegetables at a population level. 358

In conclusion, school-based programs including distribution schemes have the potential to 359

moderately improve daily consumption of fruit. However these programs do not appear to be 360

successful at improving vegetable intake in school-children. More efforts are needed to 361

design programs to improve vegetable intake in children and to reduce barriers to positive 362

(16)

Acknowledgements

364

CE put forward the initial idea to carry out the review, contributed to the searching, analysed 365

the data using meta-analysis, wrote the first draft and contributed to following drafts. MC 366

was involved in producing the original search criteria, the searching of papers and contributed 367

to all drafts. CC managed the search database, determined trial quality and contributed to all 368

drafts. DG provided essential statistical support for all analysis and contributed to all drafts. 369

JC provided essential support at all stages of the review and contributed to all drafts. We are 370

grateful to Camilla Nykjaer for checking the data. No conflict of interest was identified by 371

any of the authors. 372

373

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374

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[image:22.842.60.764.118.482.2]

Table 1: Characteristics of studies included in the review of school-based interventions to increase daily fruit and vegetable (veg) intake. Difference in fruit and vegetable portions between groups is adjusted for baseline whenever possible. Banded rows are not included in the meta-analysis.

Study name (author, year published, country) Sample size Sample age Intervention time: elements included in the intervention

Follow-up period from start of intervention

fruit & vegetable intake in portions at follow up

Difference in fruit & vegetable portions Difference in fruit portions Difference in vegetable portions Control Intervention

Nutrition Education Intervention (Anderson, 2005, UK)(71)

129 6-11 years

9 months: Curriculum, communications, food provision & marketing, food preparation/tasting

9 months 163g (2.0) 235g (2.9) 0.9 0.9 0

Gimme 5 (Baranowski, 2000, USA)(66)

3347 Mean of 8 years

9 months: Curriculum, communications, food marketing, goal setting & problem solving, home based projects

9 months

21 months

2.1 (1 year)

2.1 (2 year)

2.3 (1 year)

2.3 (2 year)

0.2

0.2

n/a n/a

Squire’s Quest

(Baranowski, 2003, USA)(67)

1489 8-12 years

5 weeks: 10 session psycho-educational multimedia game

< 3 months n/a n/a 0.9 0.5 0.2

School Fruit Program (Bere, 2005, Norway)(69)

556 11-12 years

9 months: Free school fruit & veg distribution

9 months 1.0 (median) 2.0 (median) 1.0 n/a n/a

Free School Fruit (Bere, 2006, Norway)(55)

517 10-11 years

21 months: Free school fruit & veg distribution

9 months 21 months 1.84 1.57 2.47 2.09 0.6 0.5 n/a n/a n/a n/a

Fruit & Veg Make the Marks (Bere, 2006, Norway)(56)

(23)

Study name (author, year published, country)

Sample size

Sample age

Intervention time: elements included in the intervention

Follow-up period from start of intervention

fruit & vegetable intake in portions at follow up

Difference in fruit & vegetable portions

Difference in fruit portions

Difference in vegetable portions Control Intervention

setting, home based projects

Action Schools! (Day, 2008, Canada)(85)

444 10 years 3 months: Curriculum, food tasting, school environment, goal setting

3 months 2.68 2.55 -0.23 0.13 0.1

Fruit & veg subscription (Eriksen, 2003, Denmark)

313 6-10 years

1.5 months: fruit and vegetable subscription

1.5 months 3.1 3.5 0 n/a n/a

5 a Day Power Play! School only (Foerster, 1998, USA)(60)

2684 7-9 years 2 months: Curriculum, school environment

3 months 2.3 2.9 0.6 n/a n/a

5 a Day Power Play! School & community (Foerster, 1998, USA)(60)

7-9 years 2 months: Curriculum, school environment, community

3 months 2.3 3.3 1.0 n/a n/a

The National Schools Fruit Scheme (Fogarty, 2007, UK)(64)

3382 7-8 years 12 months: fruit distribution scheme

24 months 2.0 1.7 0 n/a n/a

School Nutrition Policy initiative (Foster, 2008, USA)(86)

774 Mean of 11 years

21 months: education, policy, social marketing and parent outreach

21 months 4.3 4.2 0.0 n/a n/a

Eat Well & keep moving (Gortmaker, 1999, USA)(87)

336 Mean of 9 years

21 months: Curriculum, school environment, home based projects

(24)

Study name (author, year published, country) Sample size Sample age Intervention time: elements included in the intervention

Follow-up period from start of intervention

fruit & vegetable intake in portions at follow up

Difference in fruit & vegetable portions Difference in fruit portions Difference in vegetable portions Control Intervention

Planet Health (Gortmaker, 1999, USA)(88) 593 boys 564 girls Mean of 11.7 years

21 months: Curriculum, home based projects

21 months 3.6

3.9

3.6

3.6

0.2

0.3

n/a n/a

American Indian Nutrition (Govula, 2007, USA)(68)

33 8-11 years

2 months: Curriculum 3 months 4.7 4.9 0.2 -0.5 0.7

Cardiovascular Exercise and Nutrition Program (Hopper, 1996, USA)(57)

97 7-9 years 3 months: Curriculum, home based projects

3 months 3.9 4.4 0.4 n/a n/a

Food Dudes (Lowe, 2004, UK)(62)

36 4 to 7 years

1 month: social marketing using videos as part of curriculum

1 month n/a n/a 1.9 n/a n/a

8 to 11 years

n/a n/a 1.6 n/a n/a

Internet tailored advice (Mangunkusumo, 2006, The Netherlands)(58)

486 Mean of 10.3 years

3 months: Internet based feedback from questionnaire

3 months 2.14 2.06 0 0 0

School Fruit Tuck Shops(Moore, 2008, UK)(70)

1612 10-11 years

9 months: school environment (tuck shops selling fruit)

12 months 2.5 2.5 n/a 0.1 n/a

5 a day Power plus (Perry, 1998, USA)(72)

407 9-10 years

9 months: Curriculum, school environment, food provision/

(25)

Study name (author, year published, country) Sample size Sample age Intervention time: elements included in the intervention

Follow-up period from start of intervention

fruit & vegetable intake in portions at follow up

Difference in fruit & vegetable portions Difference in fruit portions Difference in vegetable portions Control Intervention

marketing, home based projects, industry involvement

School Fruit & Vegetable Scheme: remaining on scheme at 7 months (Ransley, 2007, UK)(52)

3405 5 years 6 months: Free school fruit & veg distribution

3 months 7 months 3.3 3.2 n/a n/a 0.7 0.2 0.6 0.3 0 -0.2

School Fruit & Vegetable Scheme: leaving scheme by 7 months (Ransley, 2007, UK)(52)

6 years 6 months: Free school fruit & veg distribution

3 months 7 months n/a n/a 0.5 -0.2 0.5 0 0 -0.3

Fruit & veg distribution program (Reinaerts, 2008, The Netherlands)(75)

436 Mean of 8 years

9 months: Free school fruit & veg distribution

9 months 21 months 1.7 1.66 2.0 1.87 0.3 0.1 0.3 0.1 0 0 Multicomponent program (Reinaerts, 2008, The Netherlands)(75)

351 Mean of 8 years

9 months: Curriculum, food provision, communications, home based projects, community 9 months 21 months 1.65 1.66 1.82 1.79 0.2 0.1 0.2 0.1 0 0

High 5 (Reynolds, 2000, USA)(65)

1426 Mean of 8.7 years

21 months: Curriculum, food tasting, problem solving, food service, home based projects

1year

2 years

2.28 (1 year)

2.21 (2 year)

3.96 (1 year)

3.20 (2 year) 1.7

1.0

(26)

Study name (author, year published, country)

Sample size

Sample age

Intervention time: elements included in the intervention

Follow-up period from start of intervention

fruit & vegetable intake in portions at follow up

Difference in fruit & vegetable portions

Difference in fruit portions

Difference in vegetable portions Control Intervention

UK)(74) 8.4 years school environment, food service

WAY program (Spiegel, 2006, USA)(63)

1007 9-11 years

9 months: Curriculum, problem solving, home based projects

9 months 0.55 0.1 0.45

Schoolgruiten project (Tak, 2007, Netherlands)(89)

450 (white)

236 (ethnic )

9-12 years

9 months: Free school fruit & veg distribution

12 months 2.54

3.07

2.83

3.3

n/a

n/a

n/a

n/a

0.1

0

APPLE (Taylor, 2007, New Zealand) (59)

288 5-12 years

9 months: Curriculum, free fruit and veg, home based projects

(27)
[image:27.595.64.546.170.734.2]

Table 2: Pooled effects of studies which excluded and included fruit juice on daily portions of fruit and vegetable consumption by subgroup analysis stratified by

randomization method, study design, length of follow up, type of dietary assessment and

children’s age.

Variables No. of

studies

Pooled estimate for sub-group (95% CI)

I2

(%)

P value for heterogeneity within sub-group

P value for heterogeneity between sub-groups

Studies excluding fruit juice

Randomization

Randomized 4 0.26 (0.12, 0.40) 1 0.39

Not randomized 4 0.26 (-0.17, 0.69) 69 0.02 0.83

Unclear 3 0.35 (-0.28, 0.98) 68 0.04

Study design

Multi-component 8 0.29 (0.08, 0.49) 40 0.11 0.47

Single component 3 0.15 (-0.26, 0.56) 67 0.05 Length of follow up

2 school years 6 0.26 (0.05, 0.47) 49 0.08

1 school year 3 0.08 (-0.29, 0.46) 48 0.15 0.90

Less than 1 school year 2 0.72 (0.14, 1.30) 0 0.53 Type of dietary assessment

24hr recall 5 0.46 (0.07, 0.86) 54 0.07

Un-weighed diary 3 0.08 (-0.29, 0.46) 48 0.15 0.31

FFQ 3 0.24(0.08, 0.40) 11 0.32

Mean age of children 16 0.02 (-0.07, 0.11) 0.68

Studies Including fruit juice

Randomization

Randomized 5 0.24(0.12, 0.35) 0 0.51

Not randomized 5 0.33(-0.13, 0.08) 67 0.01 0.40

Unclear 4 0.54(-0.04, 1.12) 78 <0.01

Study design

Multi-component 10 0.36(0.16, 0.56) 62 0.01 0.48

Single component 4 0.22(-0.25, 0.7) 68 0.03 Length of follow up

2 school years 8 0.33(0.12, 0.54) 68 0.33

1 school year 3 0.08 (-0.29, 0.46) 48 0.15 0.88

Less than 1 school year 3 0.82(0.20. 1.45) 10 0.33 Type of dietary assessment

24hr recall 6 0.58(0.20, 0.96) 64 0.02

Un-weighed diary 4 0.12(-0.11, 0.35) 39 0.18 0.14

FFQ 4 0.22(-0.02, 0.46) 42 0.16

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[image:28.595.76.515.128.386.2]
(29)
[image:29.595.75.526.178.478.2]

Figure 2: Pooled estimate of difference in daily intake of portions of fruit and

vegetables (veg) between intervention and control groups; using longest follow up data available and excluding studies that combined fruit and fruit juice. Weight was

(30)
[image:30.595.77.526.179.483.2]

Figure 3: Pooled estimate of difference in daily portions of fruit and vegetables (veg) consumed between intervention and control group; using longest follow up data available and including studies that combined fruit and fruit juice. Weight was

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[image:31.595.86.507.177.459.2]
(32)
[image:32.595.75.522.178.505.2]

Figure 5: Pooled estimate of difference in daily portions of vegetables (veg) consumed between intervention and control group; using longest follow up data available and including studies that combined fruit and fruit juice. Weight was

Figure

Table 1: Characteristics of studies included in the review of school-based interventions to increase daily fruit and vegetable (veg) intake
Table 2:  Pooled effects of studies which excluded and included fruit juice on daily portions of fruit and vegetable consumption by subgroup analysis stratified by
Figure 1: review
Figure 2:  Pooled estimate of difference in daily intake of portions of fruit and vegetables (veg) between intervention and control groups; using longest follow up data available and excluding studies that combined fruit and fruit juice
+4

References

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